Urology Practice Questions

Q: A 50 year old male patient came to the outpatient department with complaints of hematuria. A 2 x 2 cm bladder mass is seen which is low grade transitional cell carcinoma. Which among the following is the ideal management?

Transurethral resection of the tumour. ***Transurethral resection of the tumour*** - For a **low-grade transitional cell carcinoma** that is 2x2 cm and thus considered small and localized, **transurethral resection of the tumor (TURBT)** is the initial and often definitive treatment. - This procedure allows for both **diagnosis** by obtaining tissue samples and **complete removal** of the visible tumor. *Resection with ileal conduit* - This option, involving a **radical cystectomy** and urinary diversion, is a more aggressive treatment reserved for **invasive, high-grade, or recurrent bladder cancers** that cannot be managed by less invasive means. - It would be **overtreatment** for a low-grade, relatively small bladder mass. *Partial cystectomy with bladder reconstruction* - **Partial cystectomy** is considered for solitary, muscle-invasive tumors located away from critical areas (like the trigone) when bladder preservation is desirable. - It is generally not the first-line treatment for **non-muscle-invasive, low-grade tumors** due to the potential for recurrence in the remaining bladder and the morbidity of open surgery compared to TURBT. *Neoadjuvant chemotherapy* - **Neoadjuvant chemotherapy** is typically administered before radical cystectomy for **muscle-invasive bladder cancer** to improve oncologic outcomes. - It is not indicated for **low-grade, non-muscle-invasive bladder cancer** which is usually managed surgically first, without systemic chemotherapy.

Q: The complication which will not occur after PCNL surgery:

Urethral stricture. ***Urethral stricture*** - **Urethral stricture** is a complication typically associated with transurethral procedures involving instrumentation through the urethra, such as a **Transurethral Resection of the Prostate (TURP)** or repeated urethral catheterisation. - **PCNL (Percutaneous Nephrolithotomy)** involves direct access to the kidney through the skin in the flank, bypassing the urethra entirely, therefore, making urethral stricture not a direct complication of this procedure. *Organ injury* - **Organ injury**, particularly to adjacent organs like the **colon**, **pleura**, or **spleen/liver**, can occur during PCNL if the access tract is misdirected or during instrumentation. - This is a well-recognised but infrequent complication requiring careful pre-operative planning and imaging guidance. *Bleeding* - **Bleeding** is a common complication of PCNL due to the invasive nature of the procedure, involving puncture of the kidney and fragmentation of stones. - It can range from minor self-limiting bleeding to significant haemorrhage requiring transfusion or further intervention such as **angiography** and **embolization**. *Sepsis* - **Sepsis** is a serious potential complication, particularly if the patient has pre-existing urinary tract infection or if bacteria are dislodged during stone fragmentation. - **Infection** can disseminate into the bloodstream, leading to severe systemic inflammatory response syndrome and septic shock.

Q: Which of these is the best for management of a 3 cm stone in renal pelvis without evidence of hydronephrosis?

PCNL. ***PCNL*** - **Percutaneous nephrolithotomy (PCNL)** is the gold standard treatment for large renal stones (>2 cm) due to its high stone-free rates in a single procedure. - For a 3 cm renal pelvis stone, PCNL provides the best clearance rate (~95%) with minimal need for repeat procedures. - It involves direct percutaneous access to the kidney, allowing fragmentation and removal of large stone burden efficiently. *ESWL* - **Extracorporeal shock wave lithotripsy (ESWL)** has limited efficacy for stones >2 cm, with stone-free rates dropping to 50-60% for 3 cm stones. - Multiple sessions are typically required, with increased risk of steinstrasse (stone street) formation and residual fragments. - While non-invasive, ESWL is not the optimal choice for this stone size. *Retrograde pyeloplasty* - This option appears to reference **retrograde endoscopic approaches** (such as retrograde intrarenal surgery - RIRS or ureteroscopy). - While retrograde ureteroscopy can treat renal stones, it is generally reserved for stones <2 cm due to longer operative time and lower stone-free rates for larger stones. - True "pyeloplasty" is a reconstructive procedure for ureteropelvic junction obstruction, not a stone removal technique. *Antegrade pyeloplasty* - This option likely refers to **antegrade endoscopic access** to the renal pelvis. - While antegrade access is used in PCNL, "pyeloplasty" specifically means surgical reconstruction of the UPJ for obstruction, not stone treatment. - Antegrade ureteroscopy alone (without nephroscopy) would be less effective than PCNL for a 3 cm stone.

Q: Prostatic cancer mostly seen in

Posterior. ***Posterior*** - The **peripheral zone** of the prostate, which is located posteriorly, is the most common site for the development of **prostatic adenocarcinoma**. - This anatomical location is why a **digital rectal exam (DRE)** is an important screening tool, as palpable nodules can be detected [1]. *Lateral* - While prostatic tissue extends laterally, this region is not the predominant site for cancer development. - Cancers originating here are less common than those in the posterior peripheral zone. *Anterior* - The **anterior fibromuscular stroma** and the anterior portion of the prostate are rarely the primary sites for prostate cancer. - Tumors found here are often extensions from more posteriorly located cancers. *Medial* - The **transition zone**, which is located medially and surrounds the urethra, is the most common site for **benign prostatic hyperplasia (BPH)**, not prostate cancer. - While cancer can occur in this zone, it is less frequent than in the peripheral zone.

Q: A 62-year-old female had a kidney stone and was treated with PCNL. After 2 days, she comes to the OPD with chills and fever. What is the complication?

Bacterial sepsis. ***Bacterial sepsis*** - **Chills and fever** two days after a **Percutaneous Nephrolithotomy (PCNL)** are highly suggestive of a systemic infection, specifically **bacterial sepsis**, as this procedure carries a risk of introducing bacteria into the bloodstream. - Urinary tract manipulation, especially in a patient with a potentially *infected kidney stone*, can lead to bacteremia and subsequent **sepsis** if not properly managed. *Acute pancreatitis* - **Acute pancreatitis** is not a common complication of PCNL. It typically presents with severe **epigastric pain** radiating to the back, often with nausea and vomiting, and is usually associated with gallstones or alcohol abuse. - While it can cause fever, the clinical presentation and context do not strongly support **pancreatitis** as the primary issue following a PCNL. *Ureteric stricture* - A **ureteric stricture** is a *late complication* of kidney stone treatment and typically leads to symptoms of **urinary obstruction**, such as flank pain, rather than acute fever and chills two days post-procedure. - It would not cause acute systemic signs like **chills and fever** within such a short timeframe after PCNL. *Splenic injury* - **Splenic injury** is a rare but possible complication of procedures around the left kidney; however, it would typically present with **abdominal pain**, signs of **hemorrhage** (e.g., hypotension), and sometimes shoulder pain, not primarily with fever and chills as the immediate post-operative concern. - While fever can occur with internal injuries, the primary and most immediate concern with fever and chills after a urological procedure is **infection**.

Q: Bell clapper deformity (abnormal testicular fixation) predisposes to which of the following conditions?

Testicular torsion. ***Testicular torsion*** - The **bell clapper deformity** describes an abnormally high attachment of the tunica vaginalis, leaving the testis and epididymis free to rotate within the scrotal sac. - This anatomical variation allows the spermatic cord to twist, cutting off blood supply to the testis, which is the mechanism of **testicular torsion**. *Hydrocele* - A **hydrocele** is a collection of fluid in the tunica vaginalis, resulting from an imbalance in fluid production and absorption, or a patent processus vaginalis. - It is not directly caused by abnormal testicular fixation. *Testicular atrophy* - **Testicular atrophy** is a reduction in testicular size, often due to conditions like cryptorchidism, mumps orchitis, or prolonged testicular torsion, but not predisposed by the bell clapper deformity itself unless torsion occurs. - While torsion can lead to atrophy if not promptly treated, the deformity directly predisposes to the torsion event, rather than atrophy itself. *Varicocele* - A **varicocele** is an abnormal dilation of the veins of the pampiniform plexus within the scrotum, usually due to incompetent valves or venous obstruction. - This condition is not associated with testicular fixation abnormalities.

Q: Time cut-off for diagnosis of Priapism is?

4 hours. ***4 hours*** - A penile erection lasting longer than **4 hours** is the established cut-off for the diagnosis of **priapism**. - Prolonged erection beyond this duration can lead to **ischemia** and permanent cavernosal damage. *2 hours* - While concerning, an erection lasting 2 hours is typically not classified as priapism, which requires a longer duration to meet diagnostic criteria. - At this stage, the risk of significant ischemic injury is lower compared to longer durations. *3 hours* - An erection lasting 3 hours is still below the clinically defined threshold for priapism. - Although it warrants close monitoring, intervention is usually recommended once the 4-hour mark is reached. *1 hour* - An erection of 1 hour is generally considered a normal physiological response and does not meet the criteria for priapism. - This duration is insufficient to cause the microvascular damage and cellular changes associated with priapism.

Q: Route of administration of BCG for bladder cancer is

Intravesical. ***Intravesical*** - **Bacillus Calmette-Guérin (BCG)** is directly instilled into the bladder via a catheter for the treatment of **non-muscle invasive bladder cancer**. - This **intravesical** route ensures high local concentrations of the immunotherapeutic agent, stimulating an anti-tumor immune response within the bladder. *Oral* - The **oral route** is not used for BCG in bladder cancer due to poor absorption and degradation of the vaccine in the gastrointestinal tract. - It would not achieve therapeutic concentrations at the target site (the bladder) and would carry a risk of systemic side effects without localized benefit. *Subcutaneous* - **Subcutaneous administration** is typically used for systemic vaccination against tuberculosis, - However, for bladder cancer, it would not deliver the therapeutic agent directly to the cancerous tissue in the bladder lumen, limiting its efficacy. *Intravenous* - **Intravenous administration** would lead to systemic distribution of BCG, which is not desired for localized bladder cancer treatment. - It could result in significant systemic side effects, including disseminated BCG infection, without providing adequate local concentration in the bladder.

Q: Testicular tumour which responds best to radiation is:

Seminoma. ***Seminoma*** - **Seminoma** is highly sensitive to radiotherapy due to its specific histological characteristics, making it the most responsive testicular tumor to radiation. - Radiation therapy is a common and effective treatment for seminoma, particularly in early stages (Stage I-IIA), often leading to excellent cure rates (>95%). - **Low-dose radiotherapy** to para-aortic and ipsilateral iliac lymph nodes is standard adjuvant treatment. *Embryonal cell carcinoma* - **Embryonal cell carcinoma** is a non-seminomatous germ cell tumor (NSGCT) that is relatively **radioresistant**. - Treatment primarily involves **cisplatin-based chemotherapy** (BEP regimen) and/or surgery. - Radiation plays minimal role in management of NSGCTs. *Teratoma* - **Teratomas** are typically resistant to both radiation therapy and chemotherapy. - Composed of differentiated mature or immature tissues that do not respond well to systemic treatments. - The primary treatment for teratoma is **surgical excision** with retroperitoneal lymph node dissection if needed. *Choriocarcinoma* - **Choriocarcinoma** is a highly aggressive NSGCT that is **radioresistant**. - Requires intensive **chemotherapy** due to high propensity for hematogenous spread. - Radiation has no role in primary treatment, though may be used for brain metastases.

Q: All of the following are true about cryptorchidism EXCEPT:

Orchidopexy reduces the risk of malignancy. ***Cryptorchidism is a risk factor for testicular tumor*** - **Cryptorchidism**, or undescended testes, is a well-established risk factor for developing **testicular germ cell tumors**. This risk is 3- to 14-fold higher in affected individuals. - The increased risk is thought to be due to the **abnormal temperature environment** and intrinsic cellular abnormalities of the maldescended testis, leading to malignant transformation. *Contralateral testis is also at risk* - While the undescended testis has a significantly higher risk, the **contralateral (normally descended) testis** also has an elevated risk for developing a testicular tumor, though to a lesser extent. - This suggests that factors other than just temperature (e.g., genetic predisposition or inherent cellular abnormalities) play a role in the increased tumor risk. *Seminoma is the most common tumor* - **Seminoma** is indeed the most common type of testicular germ cell tumor overall, accounting for approximately 50% of all testicular cancers. - In cases of cryptorchidism, while seminoma is common, **non-seminomatous germ cell tumors (NSGCTs)** may also be more prevalent than in the general population. *Orchidopexy reduces the risk of malignancy* - **Orchidopexy** (surgical correction of cryptorchidism) can make the testis more accessible for examination and may improve fertility, but it **does not eliminate** the increased risk of malignancy. - The risk of developing testicular cancer remains elevated even after orchidopexy, especially if performed after puberty, as the cellular changes predisposing to malignancy may have already occurred.

Question 1

A 50 year old male patient came to the outpatient department with complaints of hematuria. A 2 x 2 cm bladder mass is seen which is low grade transitional cell carcinoma. Which among the following is the ideal management?

Accepted Answer

Transurethral resection of the tumour

Answer

Resection with ileal conduit

Answer

Partial cystectomy with bladder reconstruction

Answer

Neoadjuvant chemotherapy

Question 2

The complication which will not occur after PCNL surgery:

Accepted Answer

Urethral stricture

Answer

Organ injury

Answer

Bleeding

Answer

Sepsis

Question 3

Which of these is the best for management of a 3 cm stone in renal pelvis without evidence of hydronephrosis?

Accepted Answer

PCNL

Answer

Retrograde pyeloplasty

Answer

ESWL

Answer

Antegrade pyeloplasty

Question 4

Prostatic cancer mostly seen in

Accepted Answer

Posterior

Answer

Lateral

Answer

Answer

Medial

Question 5

A 62-year-old female had a kidney stone and was treated with PCNL. After 2 days, she comes to the OPD with chills and fever. What is the complication?

Accepted Answer

Bacterial sepsis

Answer

Acute pancreatitis

Answer

Ureteric stricture

Answer

Splenic injury

Question 6

Bell clapper deformity (abnormal testicular fixation) predisposes to which of the following conditions?

Accepted Answer

Testicular torsion

Answer

Hydrocele

Answer

Testicular atrophy

Answer

Varicocele

Question 7

Time cut-off for diagnosis of Priapism is?

Accepted Answer

4 hours

Answer

2 hours

Answer

3 hours

Answer

1 hour

Question 8

Route of administration of BCG for bladder cancer is

Accepted Answer

Intravesical

Answer

Oral

Answer

Subcutaneous

Answer

Intravenous

Question 9

Testicular tumour which responds best to radiation is:

Accepted Answer

Seminoma

Answer

Embryonal cell carcinoma

Answer

Teratoma

Answer

Choriocarcinoma

Question 10

All of the following are true about cryptorchidism EXCEPT:

Accepted Answer

Orchidopexy reduces the risk of malignancy

Answer

Contralateral testis is also at risk

Answer

Seminoma is the most common tumor

Answer

Cryptorchidism is a risk factor for testicular tumor

Urology — MCQs

Urology — MCQs

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